Benjamin Wei

The Safety and Efficacy of Mediastinoscopy When Performed by General Thoracic Surgeons

BACKGROUND Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons. METHODS A retrospective cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only. RESULTS Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard. CONCLUSIONS In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.

Technique and Results of Robotic Pulmonary Lobectomy Using Four Arms

Robotic assistance has been increasingly utilized for pulmonary lobectomy. Although the technical aspects of the operation require special training, robotic lobectomy possesses subjective advantages for the surgeon including better visualization of structures, the ability to control the camera rather than relying on an assistant to do so, increased range of motion of instruments, and improved ergonomics. Perioperative outcomes and overall survival following robotic lobectomy have been shown to be similar to VATS lobectomy.

Robotic Esophagectomy for Cancer: Early Results and Lessons Learned

Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

Retention Rate of Electromagnetic Navigation Bronchoscopic Placed Fiducial Markers for Lung Radiosurgery

BACKGROUND Radiosurgery is becoming an increasingly used modality for the medically inoperable early stage lung cancer patient. The optimal fiducial marker with respect to retention rate has yet to be identified. METHODS We retrospectively reviewed our experience with electromagnetic navigational bronchoscopic fiducial marker placement in preparation for stereotactic radiosurgery. RESULTS Forty-eight patients, treated between 2010 and January 2013, were retrospectively reviewed. All patients had a diagnosis of early stage lung cancer. Comparison of initial fiducial placement procedure data with imaging at the time of treatment was accomplished for all patients in this data set. Fiducial retention rates were as follow: VortX coil fiducials were retained in 59 of 61 (96.7%) cases; two-band fiducials were retained in 24 of 33 (72.7%) of instances; and gold seed fiducials were retained in 23 of 33 (69.7%) of cases. Retention was statistically superior when comparing the VortX coil with the two-band fiducial or the gold seed (p = 0.004 and p = 0.0001). Anatomic location by lobe was analyzed, but no statistically significant differences were observed. CONCLUSIONS The VortX coil fiducial marker showed a statistically significant increase in retention rate compared with gold seeds or two-band fiducials. This may translate to cost savings through placing fewer markers per patient as retention is high.

Robotic Lung Resection for Non–Small Cell Lung Cancer

Robotic-assisted pulmonary lobectomy can be considered for patients able to tolerate conventional lobectomy. Contraindications to resection via thoracotomy apply to patients undergoing robotic lobectomy. Team training, familiarity with equipment, troubleshooting, and preparation are critical for successful robotic lobectomy. Robotic lobectomy is associated with decreased rates of blood loss, blood transfusion, air leak, chest tube duration, length of stay, and mortality compared with thoracotomy. Robotic lobectomy offers many of the same benefits in perioperative morbidity and mortality, and additional advantages in optics, dexterity, and surgeon ergonomics as video-assisted thoracic lobectomy. Long-term oncologic efficacy and cost implications remain areas of study.

Robotic Lobectomy and Segmentectomy: Technical Details and Results

Robotic-assisted pulmonary lobectomy can be considered for patients fit for conventional lobectomy. Contraindications include prohibitive lung function or medical comorbidities, multistation N2, gross N2 disease, or evidence of N3 disease. Team training, familiarity with equipment, troubleshooting, and preparation are critical for successful robotic lobectomy. Similar to video-assisted thoracoscopic surgery (VATS) lobectomy, robotic lobectomy is associated with decreased blood loss, blood transfusion, air leak, chest tube duration, duration of stay, and mortality compared with thoracotomy. Robotic lobectomy offers many of the same benefits in perioperative morbidity and mortality, and the advantages of optics, dexterity, and surgeon ergonomics compared with VATS lobectomy.

Left upper lobectomy after coronary artery bypass grafting

OBJECTIVE Left upper pulmonary lobectomy or segmentectomy after coronary artery bypass grafting (CABG) risks injury to the grafts. We reviewed our experience. METHODS This is a retrospective review of a prospective database from 1 surgeon, of patients who underwent left upper lobectomy after having previous CABG. RESULTS Between June 1998 and June 2014, a total of 2207 patients underwent lobectomy by 1 surgeon; 458 (21%) had a left upper lobectomy, and 28 (6.1%) had had a previous CABG. Twenty-seven patients (96.4%) had a left internal mammary artery (LIMA) used for the bypass. Twenty-six patients (96.2%) had significant adhesions between their lung and the bypass grafts. Of patients who had a LIMA graft, 25 (92.6%) had the left upper lobe completely dissected free from their grafts, whereas 2 patients (7.1%) had a sliver of their lung left on the grafts. No patient had a postoperative myocardial infarction, and 30-day and 90-day survival rates were both 100%. All patients had a curative resection, and all had complete thoracic lymphadenectomy. CONCLUSIONS Left upper lobectomy after CABG, in patients with previous CABG and LIMA grafting, is safe. Usually the entire lung can be safely mobilized off the bypass grafts; if needed, a small sliver of lung can be left on the grafts. A curative resection is possible with minimal perioperative cardiac morbidity, and excellent 30- and 90-day mortality.

Clinical pathway for thoracic surgery in the United States

The paradigm for postoperative care for thoracic surgical patients in the United States has shifted with efforts to reduce hospital length of stay and improve quality of life. The increasing usage of minimally invasive techniques in thoracic surgery has been an important part of this. In this review we will examine our standard practices as well as the evidence behind both general contemporary postoperative care principles and those specific to certain operations.

Robotic Surgery: Techniques and Results for Resection of Lung Cancer

Abstract Robotic surgery can be used for completely portal (no utility incision) or robotic-assisted (uses utility incision) techniques. Appropriate patient and port positioning are critical for a successful performance of robotic lobectomy. Perioperative morbidity and mortality for robotic lobectomy are comparable to that for video-assisted thoracoscopic surgical (VATS) lobectomy. Robotic lobectomy may have advantages in terms of surgeon ergonomics, mediastinal lymph node dissection, and intraoperative blood loss over VATS lobectomy. To maintain safe and effective robotic surgery, surgeons must continue to design evidence-based pathways to the credentialing of robotic surgical teams. Robotic lobectomy can be done safely and is being increasingly used for anatomic pulmonary resections.

Minimally Invasive Approaches to Chest Wall and Superior Sulcus Tumors

The resection of chest wall tumors, including superior sulcus tumors, has traditionally been performed via an open approach given the extent of structures to be removed. Recently, more advanced experience with minimally invasive techniques (both VATS and robotic) have allowed thoracic surgeons to perform these operations through smaller incisions and avoid the trauma to the overlying major muscles of the chest wall. One of the earliest reports of VATS-assisted chest wall resection by Widmann et al. described performance of wedge resection of lung with VATS followed by en bloc removal of ribs 3 and 4 along with the wedge of lung, which was accomplished without the use of rib spreading [1]. More recently, Hennon et al. reported a series of 17 patients who underwent VATS chest wall resection, which comprised 36 % of overall chest wall resections done at their institution from 2007 to 2013 [2]. The utilization of minimally invasive techniques for chest wall resection has become a more common phenomenon, as surgeons explore the ways in which it may benefit patients in terms of postoperative pain and morbidity. The phrase “minimally invasive chest wall resection” (MICWR) is a bit misleading, as any chest wall resection by definition requires the resection of the same amount of bone and intercostal muscle as in an “open” operation; however the method by which this is accomplished can take advantage of some of the same tools and techniques by which VATS surgery is performed, and hence we will use the term since it reduces the morbidity of cutting muscle.